A Comparative Study of the Exposure of Newborns to the Maternal Biome through Vaginal Birth and/or Breast Feeding and Those who were not Exposed, to the Rate of Autism Spectrum Disorder in Children 3 to 5 Years of Age

Joseph Mills

College of Central Florida

 

A Comparative Study of the Exposure of Newborns to the Maternal Biome through Vaginal Birth and/or Breast Feeding and Those who were not Exposed, to the Rate of Autism Spectrum Disorder in Children 3 to 5 Years of Age 

 

               The incidence of Autism Spectrum Disorders in the United States is becoming widespread with nearly two thirds of the children born displaying some developmental disability (Amaral, Gershwind, & Dawson, 2011). This is an environmental effect that is evidenced in the lower rate of occurrence found in other countries where it appears, in only one to three percent of the children. Something in our environment or culture is causing this vast difference. There are enormous quantities of information and evidence amassing from recent studies on the human biome and gut flora and its relationship to the brain and neural development. Many of these studies seem to be supporting a correlation between an unhealthy biome in infancy and developmental neurological handicaps. This study is designed to evaluate two variations of infant exposure that may be influencing their health and developmental outcomes. This simple statistical study is designed to reveal the correlation of altered biome to later developmental anomalies. The findings from this study could impact choices and treatments that may prevent future neural developmental handicaps.

Problem Statement

               Over the past 10 years there has been an overwhelming increase in autism spectrum disorders (ASD), in children within the United States.  From 2002 to 2010 there was an average of 120% increase in cases (CDC, 2009). About 1.5% of children have been identified with ASD

according to the Centers for Disease Control (CDC, 2009). In Europe the incidence is approximately 1% and countries like South Korea average 2.6% (Rice 2009). Yet, the U.S. is approaching a staggering 67% of children with some developmental disability (Amaral, Gershwind, & Dawson, 2011). The economic impact averages $17,000 more annually for the care of a child with ASD than a child without. A child with severe disability can average $21,000 a year, with the addition of special care, training and health issues. In 2011, the additional cost of caring for these children was nearly nine billion dollars (Amaral, Gershwind, & Dawson, 2011).  With a growing disparity in the incidence, between the world rates and those of the U.S., it is imperative that the cause be identified. Multiple studies have linked infant and child gut flora with developmental disabilities, including ASD (Adams, Johansen, Powell, Quig, & Rubin, 2011; Bested, Logan, & Selhub, 2013; Borre, O’keeffe, Clarke, Stanton, Dinan, & Cryan, 2014).  Identifying causation and correlation can help with identifying options for early intervention. 

Purpose

The purpose of this study is to explore the relationship between the early exposure of a newborn child to the mother’s intrinsic flora. This exposure occurs through contact and assimilation by the infant who is breast-fed and vaginally birthed. Studying groups of infants thusly exposed in these manners will be compared to infants who have not been exposed to breast feeding or vaginal birth; thus no contact with the mother’s intrinsic flora. Infants in both groups will be followed for a period of five years while data is collected regarding developmental stages, including milestones and delays. If a significant statistical correlation is demonstrated, it can enhance decision making about the use of breast feeding and vaginal birth and perhaps influence options to affect and decrease the rise in current rates of ASD nationally and globally.  

Research Question

Does the early exposure of infants to the intrinsic maternal flora through vaginal birth or breast-feeding offer a developmental advantage against the development of autism spectrum disorders? 

Hypothesis

Experimental hypothesis (H1): Early exposure of infants to the mother’s intrinsic flora decreases the incidence of autism spectrum disorders in children.

Null Hypothesis (H0): Early exposure of infants to the mother’s intrinsic flora does not decrease the incidence of autism spectrum disorders in children. 

Significance to Nursing

The results of this study will add to the current nursing literature regarding the correlation of medical, economical, emotional and cognitive variables in the decision-making and treatment options for elective and non-elective procedures and or medical decisions with respect to the birth and care of neonates and healthy outcomes. 

Study Theoretical Framework

The American Association of Critical-Care Nurses (AACN) Synergy Model is focused on the optimal outcomes for patients that require collective contribution of the patient, their families, the nurse, the entire multidisciplinary team, the healthcare system and the community. The Synergy Model views patients as active participants in the healthcare process in the context of their environment. While the competencies and definitions of the patient and nurse are structured in a linear fashion, the relationships between each of these are non-linear. The concepts are interrelated and move towards the purpose of a holistic system in which synergy between nurse and patient can lead to optimal patient outcomes. Thus, the accountability and the responsibility for optimal outcomes are shared. This Model suggests that outcomes are derived from three sources: the patient, the nurse, and the health care system. The evidence basis of practice is brought by the nurse to the patient as a cognitive tool to help them make the best choices that further outline the standards of care and ultimately bring about better outcomes in healthcare (Hardin, 2009). This model lends itself well to a multidisciplinary approach when making cognitive changes in health practices based on collective evidence that influences both patient and system. 

Literature Review

     In the literature review, I will evaluate current research as it correlates to the early introduction and growth of a healthy gut flora in infants, to protection from ASD in early childhood. The choice of children 3 to 5 years of age is related to the findings that have shown children as early as 2 years of age and most typically by age 4, can be identified with ASD if present (Rice, 2009).  The prevalence of multiple constitutional influences in the environment of the developing infant makes the possibility of defining a sole factor in all ASD very complex and unlikely. By choosing two factors that are common in births worldwide with statistical data from my research project, I plan to investigate and correlate the same to data bases of early onset of identifiable signs and symptoms of childhood ASD. The hope is to find a significant statistical correlation that could possibly affect future outcomes. 

Research on the influence of gastrointestinal flora and its effect on children’s neurodevelopment are well developed by researchers. Borre, O’Keefe, Clarke, Stanton, and Cryan (2014), illustrated the critical neurological stages and the role of microbiota in modulating an infant’s development. What was once thought of as the brain-gut axis is now extended to the microbiota-gut-brain axis. Borre et al. (2014) discussed the bidirectional communication between the gut microbiota and the Central Nervous System (CNS), and the early life events during initial colonization and microbiota development and the role in determining general and mental health later in life. The research also pointed to the health of the maternal biome and stress as it related to the child’s development of healthy flora. Their research opened doors to the concept of transmitting the biome through vaginal birth and breast-feeding. Borre et al. (2014) concluded with the possibility for further research into therapeutic strategies early in life to combat neurodevelopmental deficits and brain disorders.

    Adams, Johansen, Powell, Quig and Rubin (2011) studied the severity of autism and the relationship to gastrointestinal (GI) flora in a comparison study with typical children. Adams et al., (2011) discussed GI symptoms and the relative correlation to autism severity. Adams et al. (2011) did not attempt a correlation of flora to the developmental contribution but simply the symptomology of GI disturbances and their higher incidence in autistic children. The study demonstrated a breakdown of beneficial and commensal bacteria counts in stool samples and possible cause and effect between bacterial constitution and GI related to severity of the autism. This research, however, was unclear as to the direct cause and effect relationship. The research only pointed out that the children with more severe autism had a higher incidence of GI disturbance. There was some attempt to correlate dietary difference with improvement in GI symptoms and the lessening of the severity of autism. See Table 1.

Table 1

ATEC score for the Autism-Low-GI-Problem group (6-GSI score of 3 or lower) and for the Autism-High-GI-Problem group (GSI-6 score above 3).

	Autism-Low-GI-Problem Group (n = 22)	Autism-High-GI-Problem Group (n = 34)	% difference	p-value from ttest
6-GSI score	1.4 +/- 0.8	5.4 +/- 1.7	+295%
ATEC-total	49.0 +/- 21	81.5 +/-27.6	+66%	0.00002
ATEC Subscales
Speech Language Communication	6.7 +/- 4.4	13.7 +/- 8.0	+103%	0.0005
Sociability	11.5 +/- 5.3	17.6 +/- 7.6	+53%	0.002
Sensory Cognitive Awareness	12.6 +/- 7.0	17.6 +/- 6.8	+40%	0.01
Health/Physical Behavior	18.7 +/- 9.1	32.6 +/- 12.0	+74%	0.00003

Adams et al. BMC Gastroenterology 2011 11:22 doi: 10.1186/1471-230X-11-22

 

 

   Bested, Logan and Selhub (2013) condensed the contemporary findings relating to intestinal bacterial overgrowth, permeability and endotoxins and their relevance to microbiota and mental health. Bested et al. (2013) discussed the need for additional studies aimed at investigating the alterations of microbiota and clinical application of probiotics. This review although condensed, was a help in focusing on the evolution of past studies. It was considerably based on the theory of ‘autointoxication’. There was some relevance to the development of mental health in contemporary contextual research.

   The field of research into the correlation of neural development, mental health and gut flora is expanding rapidly. There are many studies to date correlating the significance of a healthy biome to a healthy brain. Certainly the gut-brain relationship is well established. What my research is focused on is not so much why this occurs but, more on the, “Do we have at hand a simple natural process that could impact the outcome of autism syndrome disorders?” Thus, my research is aimed at tabulating and correlating the effect that delivering vaginally and subsequently breast feeding the newborn has on mental health in childhood.

   With the preponderance of evidence pointing to a healthy gut flora having a beneficial, if not a crucial role, in the development and maintenance of mental health and the gut-brain relationship;

I seek to find a correlation between the influence of breast-feeding and vaginal birth to the transfer and initiation of a healthy flora in neonates. 

   A recent study of the establishment of gut microbiota and breast-feeding done by Jost, Lacroix, Braegger and Chassard (2012) supported such a relationship. The research was very technical in the analysis of the composition of flora transmitted to infants through breast milk and breast-feeding. The authors did contrast the differences in neonates who did not receive breast milk. The establishment of benefit of one bacteria over another was not elucidated, simply the preponderance of species found. See Table 2.

Table 2

Gene copy numbers of the major gut-associated bacterial populations detected in neonatal feces (NF) using qPCR

Values are expressed as means ± SD at each of the three sampling points, i.e. days 4–6, 9–14 and 25–30 postnatal in neonates harboring high (A, n = 4) and low (B, n = 3) Bacteroides population levels, respectively; and comparison to means obtained from maternal feces (MF) (n = 7) over the perinatal period.

doi:10.1371/journal.pone.0044595.g002 

 

 As a base line all the neonates were vaginally birthed which helped standardize the study. The impact of nutritional components of breast milk on the establishment of beneficial bacteria and pathogens was pointed out as an opportunity for further research.

   Karlson, Molin, Cilio, and Ahrne (2010), focused on vaginally birthed infants and the correlation of birth weight and exposure to vaginal and intestinal maternal flora. Karlson et al. (2010) only pointed out the differences in infant flora of low gestational weight infants and average weight infants. See Table 3.

Table 3

Microbial differences between neonates born LGA or AGA. Phylogenetic affiliation of sequences from neonates born LGA or AGA.

Gender and birth weight (g) are indicated. Fifteen sequences from each neonate were used for clone library comparison. F, female; M, male. Escherichia  , Bacteroides  , Parabacteroides  , Neisseria  , Ralstonia  ,Clostridium  , Lactobacillus  , Enterococcus  , Staphylococcus  , Streptococcus  , Acidaminococcus  , Leuconostoc  , and Bacillus . 

 

In their conclusion, the authors noted the positive relationship of establishing a healthy ‘pioneer’ flora to later development and mental health, but further stated there is much to be studied yet on that cause and effect.

   Biasucci, Benenati, Morelli, Bessi, and Boehm (2008) compared the differences of bacterial composition in infants born vaginally as opposed to Cesarean delivery (C-section). This paper was also very focused on microbiology and analysis of fecal samples. The data concluded that the early stages of bacterial intestinal colonization were altered in infants born by Cesarean as compared to those vaginally birthed. Biasucci et al. (2009) found little difference in infants who were later breast-fed or not. However, Biasucci et al. (2009) mentioned that many of the children born by C-section did not have the benefit of breast milk as lactation was delayed among women who delivered by Cesarean section. The authors noted that further studies were needed to investigate the relationship of the strains of biota and their role in development.

   Through my investigation, the results will shed light on rates of ASD development among children who were vaginally born, and breast-fed as infants compared to those born by Cesarean section without breast feeding. 

Ethical Considerations

  Prior to any data collection, permission will be obtained to conduct this study through the Institutional Review Board (IRB) at Munroe Regional Medical Center. Each mother will be required to sign an informed consent form prior to enrollment in the study. All participants will have their names removed and will be assigned a coded number to categorize their placement in the study. Their confidentiality will be protected throughout the process. The risk to the subjects and the babies will be minimal as no real contact will be made with them following obtaining the informed consent. All information will be gathered from the mother’s health records and the child’s medical charts and records.

  The participants will be informed verbally and in writing of their right to withdraw from participation at any time without any repercussion. The individual participants will be given the researcher’s contact information in order to withdraw their data and participation from the study.  The intent to withdraw may be given verbally, in writing or e-mailed, to the responsible researcher.

  All data collected from this study will be stored on a limited access, password protected personal computer, in the researchers locked office. All field notes, personal notes and data from the study will be kept locked in an individual file to which only the researcher has the key. All files and data pertaining to the study will be kept for five years following the conclusion of the study and will at that time be permanently deleted or incinerated. 

Conclusion

                  The purpose of this study is to find a statistically significant correlation between the exposure of newborns to their mother’s intrinsic bacterial biome and the development of autism spectrum disorders (ASD). It is suspected that these variations account for the higher rate of autism, if the previous research on gut flora and early neural development is correct. Data will be collected from one thousand hospital births, 500 infants born vaginally and breast-fed and 500 infants born via C-section and not breast-fed, from across the state of Florida. Through the use of simple data collection, the number of breast-fed, vaginally birthed children at the age of five, with and without ASD (tabulated separately), will be compared to the number of children born by Cesarean section (C-section) and not breast-fed, with and without ASD (also tabulated separately). The rate of ASD in children five years of age was then compared for statistical significance for those vaginally birthed and breast fed to those born by C-section and not breast-fed. The rate of ASD was found to be significantly higher in children born via C-section and not breast-fed compared to those vaginally birthed and breast-fed. These findings were of such statistical significance as to merit discussion of limiting C-sections to absolute emergency births and the further discussion of support and education for mothers to the essential health benefit of breast-feeding to their child’s development. Further study is warranted to determine the exact mechanism of transference and composition of beneficial bacterial species, to facilitate supplementation for those infants not intrinsically exposed.  

References

Adams, J. B., Johansen, L. J., Powell, L. D., Quig, D., & Rubin, R. A. (2011). Gastrointestinal flora and gastrointestinal status in children with autism-comparisons to typical children and correlation with autism severity [Research Article]. Retrieved from http://www.biomedcentral.com/1471-230X/11/22

Amaral, D., Gershwind, D., & Dawson, G. (2011). The economic cost of autism [Review of the book Autism Spectrum Disorders, by D. Amendah, S. D. Grosse, G. Peacock, & D. S. Mandell]. Retrieved from http://Oxford:Oxford University Press

Centers for Disease Control (CDC). (2009). Autism and developmental disabilities monitoring network. MMWR, 58(10). Retrieved from http:// www.cdc.gov/

Bested, A. C., Logan, A. C., & Selhub, E. M. (2013). Intestinal microbiota, probiotics and mental health Retrieved from: http://www.gutpathogens.com/content/5/1/3 http://www.gutpathogens.com/content/5/1/3

Biasucci, G., Benenati, B., Morelli, L., Bessi, E., & Boehm, G. (2008). Cesarean delivery may affect the early biodiversity of intestinal bacteria [Article]. The Journal of Nutrition, 138, (4), 1796S-1800S. Retrieved from http://www.jn.nutrition.org

Borre, Y. E., O’keeffe, G. W., Clarke, G., Stanton, C., Dinan, T. G., & Cryan, J. F. (2014) Microbiota and neurodevelopmental windows: implications for brain disorders. Trends in Molecular Medicine, 82, (6), 1-10. Retrieved from http://dx.doi.org/10.1016/j.molmed.2014.05.002

Hardin, S. R. (2009). The AACN Synergy Model. In S. J. Peterson, & T. S. Bredow, Middle

Range Theories: Application to Nursing Research (2nd ed.). (pp. 99 - 114). Philadelphia,

PA: Wolters Kluwer Health / Lippincott Williams & Wilkins.

Jost, T., Lacroix, C., Braegger, C. P., & Chassard, C. (2012). New insights in gut microbiota establishment in healthy breast fed neonates [Research paper]. Retrieved from PLOS ONE website: http://www.plosone.org

Karlson, C. L., Molin, G., Cilio, C. M., & Ahrne, S. (2010). The pioneer gut microbiota in human neonates vaginally born at term-a pilot study [Research paper]. Retrieved from Pediatric Research website: 0031-3998/11/7003-0282

Penders, J., Thijs, C., Vink, C., Stelma, F. F., Snijders, B., Kummeling, I., Stobberingh, E. E. (2006). Factors influencing the composition of the intestinal microbiota in early infancy. Retrieved from http://www.pediatrics.org/cgi/doi/10.1542/peds.2005-2824